September 1, 2009 Features

Clinical Ladders in Speech-Language Pathology

Clinical ladders—structured hierarchies of professional levels with skill progression and competency acquisition as components of each level—have been used to recognize individual performance and to establish standards for professional advancement by nursing, physical therapy, occupational therapy, pharmacy, and other professions. As a profession, however, speech-language pathology has failed to recognize and reward clinicians for their experience and achievements using clinical ladders.

The purpose of a clinical ladder is to provide incentives for advancement, financial rewards, and professional recognition. The lack of opportunities for advancement is a problem in the profession of speech-language pathology, and clinical ladders are a potential solution—especially if they include recognition of specialty certification as a central component and recognize advanced clinical practice and specialization.

A review of the literature reveals that nursing has taken the lead in developing and implementing clinical ladders. The driving force was lack of stability of the workforce. Dating back to the early 1970s there were recurring shortages of nurses. Recognition systems with an emphasis on developing higher-level competencies began to emerge to attract and retain nurses (Bjørk et al., 2007). Higher job satisfaction overall and personal growth were realized through the implementation of clinical ladders (Malik, 1991; Meador, 1995). Nurses in the higher levels of a ladder experienced greater job satisfaction than did nurses at lower levels (Roedel & Nystrom, 1987; Schultz, 1993). Nurses who were participants in clinical ladder programs reported lower rates of turnover and intent to leave than non-participants (Corley et al., 1994; Drenkard & Swartwout, 2005; Schultz, 1993).

Speech-language pathologists can learn from the evolution of clinical ladders in nursing and tailor programs to meet the needs of SLPs. The reasons for the lack of clinical ladders for SLPs may be the paucity of research in our field in this area and a lack of attention to developing clinical ladders with higher levels for the expert clinician. This void may be undermining the profession; policies and procedures that are established generally apply to basic service provision by novice staff. Emphasis should instead be placed on developing systems of formal acknowledgement and legitimization of expertise with financial reward and clinical promotion.

Current trends may be changing, however, as suggested by the periodic requests for information on established clinical ladders from members of various speech-language pathology e-mail discussion groups.

Elements of a Clinical Ladder for SLPs

A clinical ladder recognizes skills and identifies potential for advancement based on a structured hierarchy with skill progression and competency acquisition as components of several levels, with each level tied to financial incentives (see Table 1 [PDF]). The ladder always should be a work in progress, under construction, and continually revised to keep up with the changing marketplace. A well-organized and concise clinical ladder demonstrates the program's support of the SLP's growth and clinical development and will also help attract new staff, recognize excellence, reward and compensate increased levels, reduce turnover, recognize expertise in a specific field or subspecialty, and provide the opportunity to market specialized services.

Implementing a Clinical Ladder

Implementing a clinical ladder involves identifying the culture within your facility, reviewing clinical ladders for nursing and other allied health professions, and examining ladders from similar settings in your community. Take the time to set up a clinical ladder with meaningful levels and competencies that reflect your organization's values and ideals. Consider the following steps:

  • Evaluate your setting. Consider your setting, staffing patterns, and potential for mentoring to help clinicians achieve clinical growth. Explore your team's willingness to seek an "above-and-beyond" culture. Establish goals to develop specific clinical competencies, making sure to assess and include current practices within your facility. Consider how your department celebrates individual and team achievements. Many departments are rich with mentors who inspire and teach novice staff members; if that is the case, build the clinical expertise and talents of the expert clinician into your ladder. Mentoring a novice clinician is time-consuming but valuable, and is even more valuable if the department recognizes and shows appreciation for mentoring efforts.
  • Establish performance goals. A successful program must include clearly defined performance goals, expectations, and outcomes. Begin by defining departmental and individual goals to establish a clear direction for your program. Know your staff's productivity level and set realistic goals that foster growth and learning and that encourage and reward advanced competency achievement. Include reinforcement and feedback that is prompt, frequent, respectful, and specific. Most importantly, advocate for your staff. This process will yield results especially as your staff gains clinical expertise that senior management recognize as essential to providing the highest level of patient care.
  • Set team goals for improvement. Process improvement requires people improvement. An effective approach is to ensure adequate and ongoing education/training and competency-level advancement for speech-language pathology staff. The field is constantly evolving; staff should receive support in their efforts to keep up with current research, attend conferences, and conduct research. These activities are invaluable tools to help SLPs acquire higher levels of skill that will achieve better results for patients.
  • Include financial incentives. A successful clinical ladder should include financial support to learn and to advance skills.

Learn by Doing

"Watch one, do one, teach one" is the medical student's competency structure, and the key to establishing clinical competencies is embedded in learning by practice (Lester, 1995). The structure of many clinical ladders begins with basic competencies and progresses to advanced competencies.

ASHA guidelines can provide the basis for developing clinical competencies in speech-language pathology. For example, ASHA's Knowledge and Skills for Speech-Language Pathologists With Respect to Vocal Tract Visualization and Imaging is extremely beneficial in developing competencies in laryngeal stroboscopy. To help clinicians move up the skills ladder, identify and include attendance at specific continuing education opportunities as a step toward achieving the designated competency; require clinicians to review appropriate texts and articles; and include a practicum component with close mentorship.

Enhancing Excellence

Advanced competencies can be supported through specialty certification, which is a prime example of reaching for new levels within our field. Specialty certification provides an opportunity for clinicians to highlight a particular area of interest and clinical expertise and is a means by which SLPs with advanced knowledge, skills, and experience beyond the Certificate of Clinical Competence can be recognized by consumers, colleagues, referral and payer sources, and the general public. The specialty recognition program, which ASHA initiated in 1995, includes specialty boards in child language, fluency disorders, and swallowing and swallowing disorders.

One of the major benefits of the clinical ladder program is improved retention when incentives are incorporated in each level. Clinical ladders serve to improve staff expertise level and job satisfaction, which result in improved patient outcomes and increased patient satisfaction.

Barbara P Messing, MA, CCC-SLP, is clinical-administrative director of the Milton J. Dance, Jr. Head & Neck Center at the Greater Baltimore Medical Center. She is a clinical specialist in head and neck rehabilitation and a Board-recognized specialist in swallowing and swallowing disorders. Contact her at

cite as: Messing, B. P. (2009, September 01). Clinical Ladders in Speech-Language Pathology. The ASHA Leader.

Keys to Success

In establishing a clinical ladder, consider the following elements.


  • Follow an established design (keep it clear and simple).
  • Decide on the number of critical levels to include.
  • Consider job codes and salary structure for each level (consider creating new titles or new targets within your team).

Build Consensus

  • Prepare and present your situation to senior leadership and human resources.
  • Work with your human resources department to encourage organizational structure with flexibility.
  • Be active—not passive—and consider the pace of change.

Review and Revise

  • Implement systematic and periodic review and modification of your advancement program.
  • Establish a timeline for formal review.
  • Share your program with potential new hires and keep your staff moving up the ladder (strive to retain the expert in practice for enhanced patient care).
  • Keep financial levels and incentives current by requesting periodic market analysis of SLPs.

The Dreyfus Model

The most ambitious and thoughtful work on clinical ladders was completed by Patricia Benner, who used the Dreyfus model of skill acquisition to structure the development of nursing clinical ladders. Benner characterized each of the stages from novice to expert by describing certain patterns of behavior, performance, and thinking (Benner, 2001). The Dreyfus model addresses skill acquisition by asking "How do people gain experience?" and is organized into five stages: novice, advanced beginner, competent, proficient, and expert (Thomas, 2008).

Stage 1: Novice

  • Little or no previous experience
  • May not know how to respond to mistakes
  • Vulnerable to confusion
  • Rules-based, context-free

Stage 2: Advanced Beginner

  • Some difficulty troubleshooting
  • Wants information fast
  • Can provide some advice; context required
  • Begins to formulate principles, limited holistic understanding

Stage 3: Competent

  • Develops conceptual models
  • Troubleshoots problems independently
  • Seeks out expert user advice
  • The experience of responsibility arises from active decision-making

Stage 4: Proficient

  • Intuitive diagnosis
  • Approach to problem molded by perspective arising from multiple real-world experiences
  • "Holistic similarity recognition"
  • Learner uses intuition to realize "what" is happening
  • Conscious decision-making and rules used to formulate plan

Stage 5: Expert

  • Are primary sources of knowledge and information
  • Constantly seeks new information
  • Works primarily from intuition, not reason
  • Performance degraded when forced to follow set rules

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